The biology of sex is being hotly debated, as parents, doctors and researchers reevaluate what it means to be male and female.
By Sally Lehrman, 1999
Patrick took a long time in coming -- two weeks in the birth canal -- but the moment he arrived, nurses bundled him up and rushed him out of the delivery room. The Jacksonville, Fla., hospital cloistered the eight-pound, 20 1/2-inch baby in a back section of the intensive care unit and drew the curtains. One doctor after another went to visit. The infant had a well-defined penis, but with an opening at the base, not the tip. There was just one testicle, though it was producing plenty of testosterone. In most of his cells, the baby had no Y chromosome, the one that contains the genetic instructions for the body to develop as a male. The doctors assured the adoptive mother, Helena Harmon-Smith, that Patrick was a girl. They would remove the offending appendages right away.
But Harmon-Smith had seen Patrick have an erection. Actually, several. "You're not cutting off anything that's working," she protested. The authorities checked the infant's internal organs and still insisted this baby would be better off as a girl. His mother refused. More tests. After 11 days, 20 doctors filed into a hospital conference room and solemnly announced that they would allow the family to raise Patrick as a boy. "We put him in a little tux and took him home," Harmon-Smith says.
Two and a half months later, Patrick's doctor warned his mother that the boy's testicle, really an ovotestis that also contained some ovarian tissue, was probably malignant. It should be removed -- like the one already taken from his abdomen. His mother finally agreed to a biopsy, just in case. When the surgeon returned from the operating room, he said the gonad was diseased. He had cut it off.
Harmon-Smith pestered the doctor for the pathology report for more than a month. Once she got it, "the first thing I read was 'normal, healthy testicle.' My heart stopped. I just cried," she says. Five years old March 24 and in the first grade, Patrick will never be able to produce semen.
"My son is now a non-functioning eunuch. Before, he was a functioning male," Harmon-Smith says. "I don't think the doctor cared. His reasoning was that this was a hermaphrodite, so everything should be removed."
Quietly and in near secrecy, pediatric urologists and other specialists decide what are the minimum qualifications for manhood, correcting any babies with ambiguous genitalia -- known as "intersexed" -- before their births are announced to the world. Under the urgent conditions of a medical emergency, they decide whether a smallish appendage is a proto-penis or a maxi-clitoris, and perform the surgery to make it so -- sometimes without even telling the parents the truth about their child, and rarely revealing anything to the patient as he or she grows up. Guiding the doctors' work is a commonly accepted theory, pioneered in 1955 by Johns Hopkins University sexologist John Money, that infants are psychosexually neutral at birth. If a surgeon sculpts a baby's undersized, oversized or otherwise confusing genitals to match a sex label within a few months of birth, normal psychosexual development will follow.
But evidence is building that sexual identity is not so easy to manage or mold. New studies in human development are demonstrating that the biological division between male and female isn't clear-cut or even stable. The simple presence of a Y chromosome -- considered by many people to be as male-identifying as a six-pack of Bud and a 4-by-4 Dodge Ram -- isn't necessarily enough to make a man. And frilly dresses adorning a body shaped to be female can't always contain the guy hidden inside.
The questions aren't limited to hospital birthing rooms. From sports arenas to geneticists' labs, experts are struggling to find new ways to define and describe the biology of sex. And some members of the medical establishment are beginning to question whether intersex surgeries make sense in infancy, before the child has a chance to reach puberty, develop his or her own sense of identity and give consent. Later this month, academic surgeons and pediatric urologists meet in Dallas to thrash out the psychological, hormonal, surgical and practical issues of intersex treatment. Their debates are likely to get hot.
Since the 1960s, most doctors confronted with a baby like Patrick would likely excise his penis and testicle shortly after birth and call him a girl. If he had a Y chromosome, they might keep the penis but rebuild the urethra to reach the organ's tip. If he had two XX chromosomes like most girls, but an extra-large clitoris that could be mistaken for a penis, they'd trim it back. Or if he had the right chromosomes but a very small penis, off it would go. The surgeons were certain that life without the appropriate genitals would be impossible, and as recently as last year, an article in Pediatric Nursing suggested that doctors ought to consider it child abuse if the parents refused genital remodeling.
Katherine Rossiter, the pediatric nurse practitioner who wrote the article in the January-February 1998 nursing journal, argues that intersex activists represent only a minority, albeit a vocal one, and that allowing a baby with a tiny penis and no testicles to grow up as a boy, rather than surgically reassigning him as a girl, might harm him beyond repair. But she admits that "listening to what real people say and their arguments" has broken down some of her conviction. "I've become muddy mishmash in my thinking," she says.
The medical literature and the opinions of specialists are increasingly divided. "In some cases it's led to a human tragedy -- it might have been better not to reassign the sex of this particular child. But there are cases where it's clearly right to reassign," says Raymond Hintz, an endocrinologist and professor of pediatrics at Stanford University. "It's sometimes justified, but it's not something you do lightly."
William Cromie, a Chicago pediatric urologist who serves as secretary and treasurer of the Society for Pediatric Urology, stresses that proper treatment relies on the carefully considered opinions of parents along with ethicists, endocrinologists, pediatricians and other specialists. As many as 30 conditions may lead to a child being considered intersexed. "It's not an arbitrary, capricious decision by one person," he says. "You try to make the very best decision -- it's usually ground over by a lot of people who are very thoughtful. This is an area that's immensely complex. And lay people just plain and simple don't understand it."
However well-meaning, though, doctors who perform intersex surgery employ a very finite tool in making their decision. The first measure of manhood is a ruler: If a penis is less than one inch (2.5 centimeters) at birth, it doesn't count. And if it's more than three-eighths of an inch (0.9 centimeters) long, it can't qualify as a clitoris either. Any appendage that falls in the middle must be fixed. Then there's the question of the urethral opening, which must be in the right place -- men don't pee sitting down. A curving penis must also be corrected.
For a boy to be a boy, he ought to have two testicles just below a straight penis, and only one opening down there. If the genitals fall short, a pediatric urologist will almost always assign the infant a female gender, remove anything protruding too far and prescribe estrogen at puberty. A talented surgeon can construct a vagina using a piece of the bowel, although the woman who owns it will never experience any sensation inside.
Hale Hawbecker narrowly escaped such a prognosis. When he was born in 1960, his doctors, aghast at his small, perfectly formed penis and internal testicles, wanted to reassign him female. His parents refused, not comprehending the doctors' distress. "It's kind of a strict club in this country to be a man, with very rigid rules to qualify," says Hawbecker, now a Washington attorney who is developing a legal challenge to infant intersex surgeries in his spare time. "It doesn't matter if you're XY. If your penis is too small, you lose it."
- Next >>